Failure to Administer Medications as Ordered and Follow Physician Parameters
Penalty
Summary
The facility failed to administer medications as ordered by physicians for four residents. In multiple instances, residents did not receive prescribed medications, including Aspirin, Quetiapine, Atorvastatin, Calcium Carbonate, Docusate, Levetiracetam, Metformin, Senna, Warfarin, and Morphine, despite these medications being available as stock or in the facility's emergency kit (RX Now system). Documentation and interviews confirmed that these medications were not given as ordered, and in some cases, the Medication Administration Record (MAR) incorrectly indicated that medications were on hold pending pharmacy delivery, even though they were available on-site. For one resident experiencing severe pain, Morphine was not administered as ordered, and for another, several routine medications were omitted. Additionally, the facility failed to follow specific physician parameters for insulin administration for one resident. Insulin was administered on seven occasions when the resident's blood glucose was below the threshold specified in the physician's order, which directed staff to hold the medication for blood glucose less than 110. These failures were confirmed through MAR reviews and staff interviews, indicating a pattern of not adhering to physician orders for medication administration.